Accountable Care Systems: Moving at a pace and scale that doesn’t allow us to learn from the immediate past?

There is a current push to create Accountable Care Systems in the NHS, but does anyone really know what they are, exactly who will need to be involved in their creation, operation and oversight and have we yet learnt the lessons of previous models? asks Dr Anna Coleman.

Accountable Care Systems (ACS) have been designed as the ‘next step’ in the evolution of Sustainability and Transformation Partnerships

ACSs will have wider authority to plan and finance local healthcare provision in their areas

A common theme in analyses of ACS plans centre around the speed of change and potentially unrealistic expectations

A more considered approach – taking time to learn lessons from various recent pilot schemes, set expectations, and define success – would make for the better implementation of this ambitious plan

According to NHS England, an Accountable Care System (ACS) in England should “bring together local NHS organisations, often in partnership with social care services and the voluntary sector” to create locally joined-up services and reduce fragmentation across the system. It is also claimed that “They build on the learning from and early results of NHS England’s new care model ‘vanguards’, which are slowing emergency hospitalisations growth by up to two thirds compared with other less integrated parts of the country” – but is this really the case?

The Five Year Forward View (FYFV, 2014) set out a vision of what the future of the health care system would look like – focusing on prevention, empowering patients, engaging communities and utilizing new models of care. Subsequently, 50 Vanguard sites were selected to take a lead on the development of new care models which were to “act as the blueprints for the NHS moving forward and inspire the rest of the health and care system”(NHSE). The FYFV set out an approach focusing on service improvements and outcomes; co-production of major national improvement strategies; evolution over time; and supporting leadership and existing energy in the system. A follow-up document – Next Steps on the NHS Five Year Forward View (2017) – concentrated on what should be achieved over the next 2 years and how the Forward View’s goals would be implemented.

Accountable Care Systems – the next step for STPs?

During the last 18 months, Sustainability and Transformation Plans / Partnerships (STPs) have been developed across England. These are 44 geographical units of planning for health and care where local organisations collaborate to reach consensus about changes to services. According to the Next Steps document, some areas are ready to “go further and more fully integrate their services and funding” as Accountable Care Systems (ACSs). ACSs will take on a collective responsibility for resources and population health across their area in order to try to provide joined up, better coordinated care. It is said that they will have more control over the whole operation of the local health system and will need to work closely with local government and other partners. The ‘Next Steps’ document suggests ACSs are ‘evolved’ versions of STPs – or groups of organisations within an STP sub-area – that can:

Manage funding for their defined population making use of shared performance goals and set spending envelope (‘control total’) for health services across Clinical Commissioning Groups (CCGs) and providers;

Establish a collective decision making and governance structure;

Show that provider organisations can operate on a horizontally integrated basis (e.g. one hospital covering several sites);

Show vertical integration (e.g. partnering with local GP practices);

Deploy rigorous and validated population health management that encourages patient activation and self-care;

Enable patient choice for elective care and personal budgets.

In addition, it is suggested that local commissioners be able to access devolved transformation funding from 2018, and that regulatory arrangements with NHSE and NHSI will be streamlined. Managerial support is to be provided by the redeployment of NHSE / NHSI staff. However, these things are not straightforward to achieve, and some aspects may require changes to primary legislation.

To date 8 ACSs have been named alongside a new devolution agreement (similar to Greater Manchester) in Surrey Heartlands, with others predicted to follow. The most recent, the London Health and Social Care devolution programme, was announced on 15/11/17. NHS England state that “the first wave of ACSs are already assuming accountability for local operational and financial performance” and that “from April 2018, they will begin to gain new financial flexibilities and to use new tools for better understanding local health data”.

Forcing the pace of change – concerns remain

Holder and Buckingham point out the degree of churn in the NHS: ‘commissioning organisations have been redesigned and restructured 7 times since 1991. The creation of STPs and ACSs [alongside local health and care devolution deals] being the 8th. Unlike previous changes this one also impacts directly on provider organisations’. Against this background, how likely is it that all that is claimed will be achieved?

In order to explore this question, the King’s Fund looked at a similar system in Canterbury, New Zealand. Change was ‘achieved through developing a number of new delivery models’, ‘integrated working and new contracting forms’ and ‘a clear unifying vision and budget’, but also took significant time and investment. It is perhaps this which gives most cause for concern in England. Despite the rhetoric of evolution, systematic evaluation and risk management, the development of ACSs is going ahead before the lessons from Pioneers, Vanguards, health and care devolution deals (e.g. Greater Manchester, Cornwall) and the early operation of STPs have been fully assimilated.

West (2017) suggests that the advantages offered to ACSs – such as development funding and simplified regulation – may create pressures for local areas to embrace the initiative whether or not they are in a position to deliver. He also questions ACSs ability to quickly slow demand and cost growth and highlights the unrealistically high expectations of other initiatives such as Pioneers and Vanguards in tackling these perennial problems. Dunhill (2017) also suggests that there remain many issues impeding the potential for significant structural reforms, including unsuitable contract types; instability of NHS trusts; VAT liability and exemption issues; and engagement of GPs and local authorities.

Pause for thought – learning lessons and defining success

It is unclear how STPs / ACSs will be ‘measured’ for success or regulated as a whole under existing legislation, and accountability mechanisms are as yet uncertain. There are also unanswered questions relating to: what operational structures and business models will be utilised; how GP practices/federations will fit into the new models; methods of oversight; patient choice and involvement; how good practice will be shared; and overall cost.

There is a danger that, in the quest to move forward and change at such a pace, we are missing the opportunity to learn lessons from all of the new initiatives established since 2015. Many of these – Pioneers, Vanguards, Devolution – are still in the very early stages of establishing new ways of doing things, and evaluations are not yet complete.

These are complicated, wide-ranging changes which require organisations to work together and change how they do things like never before. So why would we not reflect on the good and bad that went before and learn from those who have tested some of these developments? Corrigan (2017) suggests that “new care models are meant to achieve three things. They’ve got to be new, they’ve got to care, and they have to be a model” and that it’s the third of these that is proving most complicated. “How do you shape a number of very different activities in a number of very different locations into a single model of new care?” He goes on to state that “Knocking the different edges off and saying this is the core activity that we need to spread is something that the NHS has to learn a lot more about”.

There are ongoing local and national evaluations of Pioneers, Vanguards and Devolution. Pausing for a moment, assimilating the lessons learned and adjusting potentially unrealistic expectations might be time well spent.